A Chance To Grow

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  • Home
  • About
    • Mission
    • History
    • Board of Directors
    • Honorary Spaces
    • Annual Report
    • Contact
  • Programs + Services
    • Clinical Services >
      • Client Forms
      • Occupational Therapy
      • Speech Therapy
      • Neuro Integrative Clinic >
        • Treatment Models
      • Audiology Services >
        • Auditory Processing
        • Workshops
        • Auditory Interventions >
          • JIAS
          • CAPDOTS
          • Acoustic Pioneer
      • Vision Services >
        • OptomEYES Vision Therapy
      • Insurance Payers
      • Teletherapy Services
    • Neurofeedback >
      • Neurofeedback Rentals
      • Audio-Visual Entrainment
    • Home-Based / PCA's >
      • Get Started
      • Waiver Services
      • Intake Form
    • S.M.A.R.T. / MLRC >
      • S.M.A.R.T. Program >
        • How S.M.A.R.T. Works
        • S.M.A.R.T. at My School
        • S.M.A.R.T. Mentoring
        • Research & Resources
      • Workshops >
        • S.M.A.R.T. Elementary
        • S.M.A.R.T. Pre-K
        • Bridging The Gap
        • Auditory Processing Workshops
        • Hosting a Workshop
        • Graduate Credits
        • Registration Policy
      • S.M.A.R.T. Supplies >
        • Downloads
    • School-Based Services >
      • Third-Party Billing
    • Turnquist Childcare >
      • Curriculum + Assessment
      • Teen Parent Program
  • Events
    • Workshops
    • Race for the Children
    • Partners + Sponsors
  • Store
    • Shipping & Returns
  • Parents
    • Helpful Resources
    • Testimonials
    • Share Your Story
  • News + Media
    • Growing Times
    • S.M.A.R.T. Newsletter
    • Success Stories
    • Photo Release
  • Donate
    • Bob's Legacy Fund

Insurance and Service Authorization Form


​Please fill out the form below indicating your insurance preference. After you have completed a page, please hit "Next" to go to the following page. Once completed, select "Submit" and your form will be forwarded to the appropriate staff member.

​If you prefer to fill out your insurance authorization on a physical form, we invite you to download the 
Insurance and Service Authorization Form, complete and fax it to us at (612) 706-5555. Please print completed documents for your personal records. You may also fill out the form on your computer and upload a completed PDF version in the upload form box below. 

If you have questions or need more information, please contact us at (612) 789-1236 or email rehabclinic@actg.org.
Download Insurance Auth. Form
Data Privacy
We invite you to visit our Privacy Practices page to review our policies regarding the security of your information. This page describes how medical information about you may be used and disclosed and how you can get access to this information.

Your Personal Health Information (PHI) may be used and disclosed to those who are involved in your care for the purpose of providing, coordinating, or managing your services. This includes consultation with clinical supervisors or other team members. Your authorization is required to disclose PHI to any other care provider not currently involved in your care.

​Example: If another physician referred you to us, we may contact that physician to discuss your care. Likewise, if we refer you to another physician, we may contact that physician to discuss your care or they may contact us.
​

If you have questions or need more information, please contact us by calling (612) 789-1236 or email rehabclinic@actg.org.
Our Mission is to promote the maximum development of the whole child and adult through innovative, individualized and comprehensive brain-centered programs and services.
Location
1800 NE 2nd Street, Minneapolis, MN 55418
(612) 789-1236 / actg@actg.org
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A Chance To Grow is a 501(c)(3) non-profit organization. Gifts are tax-deductible. ACTG does not discriminate on the basis of race, sex, religion, age, disability, sexual orientation, or marital status.
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